by Robert S. Mendelsohn, M.D.
Chapter 3: Confessions of a Medical Heretic by Dr Robert Mendelsohn, ISBN 0809277263
Appendectomies - Tonsillectomies - Hysterectomy - Childbirth Forceps - Episiotomy - Caesarean - Fetal monitoring - Coronary bypass surgery - Modern cancer surgery - Circumcision
I believe that my generation of doctors will be remembered for two things: the miracles that turned to mayhem, such as penicillin and cortisone, and for the millions of mutilations which are ceremoniously carried out every year in operating rooms.
Conservative estimates—such as that made by a congressional subcommittee—say that about 2.4 million operations performed every year are unnecessary, and that these operations cost $4 billion and 12,000 lives, or five percent of the quarter million deaths following or during surgery each year. The independent Health Research Group says the number of unnecessary operations is more than 3 million. And various studies have put the number of useless operations between eleven and thirty percent. My feeling is that somewhere around ninety percent of surgery is a waste of time, energy, money, and life.
One study, for example, closely reviewed people who were recommended for surgery. Not only did they find that most of them needed no surgery, but fully half of them needed no medical treatment at all! The formation of committees to review tissue removed in operations has resulted in some telling statistics. In one case, 262 appendectomies were performed the year before a tissue committee began overseeing surgery. During the first year of the committee's review, the number dropped to 178. Within a few years, the number dropped to 62. The percentage of normal appendices removed fell fifty-five percent. In another hospital, the number of appendectomies was slashed by two-thirds after a tissue committee went to work.
These committees and study teams are composed of doctors who are still working within the belief system of Modern Medicine. There are dozens of common operations they would no doubt see as useful most of the time, such as cancer surgery, coronary bypass surgery, and hysterectomies. Yet as far as I'm concerned, ninety percent of the most common operations, including these, are at best of little value and at worst quite harmful.
The victims of a lot of needless surgery are children. Tonsillectomy is one of the most common surgical procedures in the United States. Half of all pediatric surgery is for the removal of tonsils. About a million are done every year. Yet the operation has never been demonstrated to do very much good.
Back around the same time I got into trouble for cutting urological workups on children at an outpatient clinic, I got into trouble again for not discussing the size of tonsils. There are very rare cases—less than one in 1,000—where someone may need a tonsillectomy. I'm not talking about when the child snores or breathes noisily. But when it really impedes the child's breathing, if he or she is really choking, the tonsils may have to come out. You don't have to ask a child or a parent about it. It's obvious! So I cut out that question on the examination. Of course, the number of tonsillectomies went way down. As you might expect, I soon got a call from the chairman of the ear, nose, and throat department: I was threatening his teaching program.
Tonsillectomies have been performed for more than 2,000 years, and their usefulness in most cases never has been proved. Doctors still can't agree on when the operation should or shouldn't be performed. The best reason doctors and parents can give for the attack on the tonsils is, as if they were some mountain range that had to be conquered, "because they're there."
Parents are lulled into believing that the operation "can't do any harm." Though physical complications are rare, they're not altogether non-existent. Mortality ranges in different surveys from one in 3,000 to one in 10,000. Emotional complications abound. Getting to eat all the ice cream you want doesn't make up for the justified fear a child experiences that his parents and the doctor are ganging up on him. A lot of children show marked changes for the worse in their behavior after the operation. They're more depressed, pessimistic, afraid, and generally awkward in the family. Who can blame them? They can sense, and unfortunately be seriously affected by, a patently absurd—though dangerous—situation.
Women also seem to be the victims of a lot of unnecessary surgery. Another operation steadily climbing towards the million-a-year mark is the hysterectomy. The National Center for Health Statistics estimated that 690,000 women had their uteruses removed in 1973, which results in a rate of 647.7 per 100,000 females. Besides the fact that this is a higher rate than for any other operation, if the rate continued, it would mean that half of all women would lose their uterus by age 65! That's if the rate holds steady. Actually, it's growing. In 1975, 808,000 hysterectomies were performed.
Very few of them were necessary. In six New York hospitals, forty-three percent of the hysterectomies reviewed were found to be unjustified. Women with abnormal bleeding from the uterus and abnormally heavy menstrual blood flow were given hysterectomies even though other treatments—or no treatment at all—would have most likely worked just as well.
In their lusting after the status and power of surgeons, obstetricians are rapidly turning the natural process of childbirth into a surgical procedure. Layer upon layer of "treatment" buries the experience under the mantle of sickness, as each layer requires another layer to compensate for its adverse effects. Strangely enough, you can always count on doctors to take credit for the compensations, but not for the medical disasters that make the compensations necessary in the first place!
The first major intrusion into childbirth was the introduction of forceps. Two sinister sixteenth-century barber-surgeons, the Chamberlen brothers, always carried a huge wooden box into the delivery room. They sent everyone else out of the room and blindfolded the mother in labor before opening the box. It wasn't until the nineteenth century that the contents of the box became widely known: obstetrical forceps. Using forceps to extract the baby whether or not the birth proceeds normally was the first step towards turning labor and delivery into surgery.
The next step came as scientists became interested in the birthing process. Doctors began to compete with midwives, and as they won, the process came to be supervised by the male doctor rather than the female midwife. It wasn't long before childbirth moved from the home into the hospital, where all the trappings and stage settings for treating it as a disease could be easily arranged. Of course, when the male doctors took over childbirth, it did become a disease. The doctors did something the midwives never did: they went right from the autopsy labs where they were handling corpses to the maternity wards to attend births. Maternal and infant death rates skyrocketed far beyond where they had been when midwives delivered babies. One courageous doctor, Ignaz Philipp Semmelweis, pointed out the deadly connection and was hounded out of medicine and into an insane asylum for suggesting that doctors were the agents of disease. Once Semmelweis' suggestion that doctors wash their hands before attending a birth was adopted, maternal and infant mortality rates dropped—an event for which the profession predictably took credit.
Once it became possible to drug the mother into a state of helpless oblivion, the obstetrician could become even more powerful. Since the mother couldn't assist in the delivery while unconscious, the forceps' place in the delivery room was assured.
Sedated, feet in stirrups, shaven, attached to an intravenous fluid bag and a battery of monitors, the woman in labor is set up so well for surgery, an operation had to be invented so the scene wouldn't go to waste. Enter the episiotomy. So routine is this surgical slicing of the perineum to widen the opening of the vagina that few women and even fewer doctors think twice about it. Doctors claim that the surgical incision is straighter and simpler to repair than the tear that is likely to occur when the baby's head and shoulders are born. They fail to acknowledge that if the woman is not drugged silly, and if she's properly coached by someone who knows what's going on, and if she's prepared, then she will know how and when to push and not push to ease the baby out. When the birth is a conscious, deliberate experience, the perineal tear can usually be avoided. After all, the vagina was made to stretch and allow a baby to pass through. Even if tearing does occur, there's no evidence that the surgical incision heals better than a tear. Quite the contrary, my experience demonstrates that tears heal better, and with less discomfort, than episiotomies. There is some feeling that the episiotomy may lead to a later lessening of sexual pleasure.
Obstetricians were not long satisfied by the minor surgery of the episiotomy. They had to have something more awesome and dangerous. After all, the delivery room setting only adds to the feeling that something terribly abnormal must be happening here. And such an abnormal process surely demands medical intervention. The more extreme the better. And since the delivery room is really an operating room disguised by the simple addition of an incubator, what really should be going on here is a full blown operation. Hence the obstetrical sacrifice graduates beyond the simple mutilation of the episiotomy to the most sinister development of modern obstetrics, the epidemic of Caesarean deliveries.
Fetal monitoring—listening to the fetal heart either through the mother's abdomen or, most recently, through electrodes screwed into the infant's scalp during labor—is the diagnostic sowing procedure that is reaping the harvest of Caesarean section deliveries. Whether or not the fetus is really in trouble, if the monitor says something is wrong, there's a rush to slice the mother open and remove the baby. Then the obstetrician can bask in all the limelight that comes with performing a miracle. After all, he's snatched a life from the jaws of certain death or disablement. Studies of comparable deliveries show that Caesarean deliveries occur three to four times more often in births attended by electronic fetal monitoring than in those monitored with a stethoscope. That's not so hard to understand.
If the mother doesn't want the operation, all the obstetrician has to do is point to the distressed blips on the monitor screen. That's reality, what appears on the cathode ray tube, not what the woman feels and wants.
A woman has plenty of other reasons not to want her delivery electronically monitored. In order to attach the electrodes to the fetus' scalp, the bag of waters must be artificially broken. This results in an instant depression of the fetal heart rate. In one study, children whose birth was electronically monitored were sixty-five percent more likely to suffer behavioral or developmental problems later in life.
Of course, what the woman feels and wants is secondary to what the obstetrician says must be. And that includes scheduling the delivery according to the doctor's convenience. In many hospitals the induced, "nine-to-five" delivery has become the rule. Working only from his calculations of when the baby is due—which can be off by as much as six weeks!—the doctor induces labor when he feels like it, not when the baby is naturally ready to pass through the birth canal. A labor induced by the doctor can end up a Caesarean delivery because a baby that's not ready to be born will naturally show more distress on fetal monitors, distress at being summoned prematurely.
Fetal lung disease, failure of normal growth and development, and other mental and physical disabilities associated with premature birth are dangers of induced delivery. As many as four percent of the babies admitted to newborn-intensive care nurseries come in after medically induced deliveries. Mothers, too, are more likely to end up in the intensive care ward after an induced delivery. Postoperative complications occur in half of all women who deliver by Caesarean section. And the maternal death rate is 26 times higher than in women who deliver vaginally. I propose that we drop the term fetal monitoring and start calling it fatal monitoring!
Full-term, regular size babies delivered by Caesarean section are also in danger of a serious lung condition known as hyaline membrane disease or respiratory distress syndrome. This poorly understood, sometimes fatal, and usually unresponsive to treatment condition was once found almost exclusively in premature infants. If a baby delivers normally, the compressing action of the uterus squeezes the chest and lungs as the baby emerges. The fluids and secretions that accumulate in the lungs are then propelled through the bronchial tubes and expelled through the mouth. This does not take place in Caesarean babies.
One study concluded that the incidence of this disease could be reduced at least fifteen percent if obstetricians were more careful about Caesarean deliveries. The same report stated that at least 6,000 of the estimated 40,000 cases of hyaline membrane disease could be prevented if doctors didn't induce delivery until the fetus was mature enough to leave the womb.
Yet the rates of induced deliveries and Caesarean sections are going up, not down. I can remember when if a hospital's incidence of Caesarean deliveries went above four or five percent, there was a full scale investigation. The present level is around twenty-five percent. There are no investigations at all. And in some hospitals the rate is pushing fifty percent.
We tend to get the idea that medicine is always progressing and that surgical procedures are developed, proved useful, and incorporated into everyday practice—at least until they are supplanted by the next "miracle." But that's not the way it happens at all. Surgery goes through three phases, but none of them has the least to do with progress. The first phase a new surgical procedure goes through is enthusiastic acceptance. Of course, the natural order of things says that a new development should be treated with skepticism before enthusiasm. But that's not the way things work in Modern Medicine. Once an operation is proved possible, its enthusiastic acceptance is guaranteed. Only after an operation has been around for some time and the real usefulness and abusefulness have had plenty of chances to emerge from the fog of early enthusiasm, does skepticism begin to seep in from around the edges.
Coronary bypass surgery
Coronary bypass surgery enjoyed unbounded acceptance for the first five or six years. Everyone acted like the operation, in which a blood vessel clogged by fat deposits is surgically "bypassed," was the answer to the catastrophic rate of death by heart attack in the United States. But the lily hasn't been able to stand up to the gilding process. Though tens of thousands of men and women still line up for this operation every year, more and more people are getting skeptical. Apparently, the operation doesn't work as well as surgeons would like to think. A seven-year study by the Veterans Administration of more than 1,000 people found that except for high-risk patients with rare left-main artery disease, the coronary bypass provided no benefit. Mortality rates for surgery patients were not significantly different from those medically treated. In fact, among the low-risk patients, the mortality rates after four years were slightly higher among those receiving the operation. Other studies have shown that people who have coronary bypass surgery still show abnormalities on exercise EKG tests and that they have no less risk of suffering a heart attack than those who are treated nonsurgically. Though the operation seems to provide relief from angina pain, some doctors believe this may be either a placebo effect or the result of surgical destruction of nerve pathways. Furthermore, the bypass itself can become clogged and leave the patient right back where he or she started before the operation.
The most effective treatment for heart disease appears to be a radical change in diet from the typical high fat to one in which fat makes up ten percent or less of total calories, combined with a progressive exercise regimen. This treatment has demonstrated evidence of healing as well as relief from symptoms.
All of which will eventually push the coronary bypass into the third phase: abandonment.
But operations die hard, especially enormously profitable ones like the bypass. Although it's fairly obvious that replacing a two or three-inch section of a clogged large vessel isn't going to do anything for the 99.9 percent of clogged arteries that are left, the bypass operation still packs 'em in. Fortunes, careers, and lives still depend on it.
Perhaps what it will take to put the bypass under for good is the kind of courage it took one surgeon to pound the last nail into the coffin of "poudrage," a heart operation that was popular a few decades ago. In this operation, they would open up the chest and simply sprinkle talcum powder on the outside of the heart. Presumably, this would irritate the linings and the vessels so they would develop new blood vessels and increase circulation. Poudrage was all the rage until a surgeon took a series of patients for the operation, opened all their chests, but sprinkled the powder on only half of them. The results were exactly the same. They all felt the same after surgery!
Once a surgical procedure is abandoned by all rational pretense, it isn't necessarily abandoned by Modern Medicine. If you take the major categories of surgery, most reached this point years ago. Their real usefulness is hard to find, but they overflow with sacramental benefits. As rituals of the Church, they never die. Although tonsillectomies should have been for all practical purposes abandoned for 2,000 years, they're still quite popular as a medical ceremony. Ophthalmologists scare the hell out of parents by telling them their child will develop blindness in one eye if his or her mild crossed eye syndrome isn't surgically corrected. If that were true, we would have millions of people walking around blind in one eye, since that's how many cases never reach the ophthalmologists.
And though the bloom is off the rose as far as the coronary bypass is concerned, doctors in Modern Medicine's sacrament mill are developing the same basic—and useless—technique for use on other forms of cardiovascular disease!
Modern cancer surgery
Modern cancer surgery someday will be regarded with the same kind of horror that we now regard the use of leeches in George Washington's time. It was shown to be irrational thirty-five years ago when Warren Cole at the University of Illinois showed that if you examine the peripheral blood after you open the skin, you find that as a result of surgery the tumor cells have already spread. Doctors answered that by saying of course the tumor spreads, but the rest of the body can take care of it. That's a silly answer. If the person's body could "take care of it," the person wouldn't have cancer in the first place! Some say that cancer surgery is threatened because of all the new techniques for fighting cancer. It's the other way around: the new techniques are capturing people's imagination and hope because cancer surgery is proving a disappointment. Your surgeon, nonetheless, will be the last to admit this.
People ask me why there's so much unnecessary surgery, and I tell them there are more reasons why there should be than there are that there shouldn't be. The only reason why there shouldn't be so much unnecessary surgery is that it causes suffering and loss of life, health, and expenses that do not have to be. That consideration alone has never had much effect on the workings of the Church of Modern Medicine. On the other hand, the reasons why there should be unnecessary surgery are legion, and quite compelling within the ethical framework of the Church.
The simplest reason is that surgery can be put to many uses besides the stated purpose of correcting or removing a disease process. Surgery is a great teaching tool as well as a fertile experimental field—although the only thing that's ever "learned" or "discovered" is how to perform the surgery. When I was Senior Pediatric Consultant to the Department of Mental Health in Illinois, I cut out a certain kind of operation that was being performed on mongoloid children with heart defects. The stated purpose of the operation was to improve oxygen supply to the brain. The real purpose, of course, was to improve the state's residency programs in cardiovascular surgery, because nothing beneficial happened to the brains of mongoloid children—and the surgeons knew that. The whole idea was absurd. And deadly, since the operation had a fairly high mortality rate. Naturally, the university people were very upset when I cut out the operation. They couldn't figure out a better use for the mongoloid children, and, besides, it was important to train people.
Greed plays a role in causing unnecessary surgery, although I don't think the economic motive alone is enough to explain it. There's no doubt that if you eliminated all unnecessary surgery, most surgeons would go out of business. They'd have to look for honest work, because the surgeon gets paid when he performs surgery on you, not when you're treated some other way. In prepaid group practices where surgeons are paid a steady salary not tied to how many operations they perform, hysterectomies and tonsillectomies occur only about one-third as often as in fee-for-service situations.
If we had about one-tenth as many surgeons as we have now, there would be very little unnecessary surgery. Even the American College of Surgeons has said we need only 50,000 to 60,000 board certified surgeons, plus about 10,000 interns and residents, to provide amply for the country's surgical needs for the next half century. According to their projections—which we would expect to be considerate of the financial plight of surgeons if their suggestions were taken seriously—almost half of the 100,000 or so surgeons we actually do have right now are superfluous. Those 50,000 or so extra unsheathed scalpels do a lot of damage.
Ignorance plays a part in a lot of unnecessary surgery, too. I don't mean ignorance on the part of the patients. If, for example, you eliminated all gynecological surgery that resulted from improper, outdated, and outright stupid obstetrical-gynecological practice, there wouldn't be much gynecological surgery left. Doctors know full well, for instance, that women who experience menstrual irregularities are more prone to develop vaginal or cervical cancer if they take oral contraceptives. In fact, the risk for some of these women, depending on what caused their menstrual irregularities, is more than ten times the already increased risk! Yet few doctors bother to find out who these women are before they put them on the Pill. I know of one woman who was taking the Pill for years— unadvised of the danger she was in. She had severe bleeding during her first period, an incident that marked her as someone who should not take the Pill. Even when her checkup revealed—via a Pap smear—that something irregular was going on, her gynecologist told her not to worry since she could always get a hysterectomy. Apparently, his motives were a mixture of greed and ignorance, because the next doctor she went to told her that if she didn't have a relatively minor surgical procedure right away, she would definitely need a hysterectomy within a few years. But even that minor operation could have been avoided had her doctor informed her of the danger she was in the moment she started taking the Pill.
Greed and ignorance aren't the most important reasons why there is so much unnecessary surgery, however. It's basically a problem of belief: doctors believe in surgery. There's a certain fascination in "going under the knife," and doctors take every advantage of it to get people there. After all, surgery is an element of Progress, and Progress separates us from those who came before us and from those we aresurpassing. In America, what can be done will be done. Whether something should be done is beside the point. As long as we can build the tools and do it, it must be the right thing to do. So not only do we have coronary bypasses, tonsillectomies, and radical mastectomies—but transsexual surgery as well.
The first surgery was religious, and ninety percent of the surgery performed today is also religious. The Jewish ritual circumcision, or bris, has a place in Jewish law and culture. The bris is performed on the eighth day of life by a trained mohel who uses the same technique that has withstood more than 4,000 years of use. Ten men stand by to make sure he does it right, too. Modern Medicine's routine circumcision, however, takes place on the first or second day of life, when blood loss can be especially dangerous. It's performed by a surgeon, or an intern, or a medical student using the "latest" technique. Where the bris ceremony includes pouring some wine in the infant's mouth, no anesthetic at all is used in Modern Medicine's ritual.
Routine circumcision of all males makes no sense outside of a religious framework. A circumcision is an operation, and its dangers are not inconsiderable. It's not altogether rare for a surgeon to get smart and use cautery instead of a knife—and to slip and burn off most of the penis.
In some primitive religions submitting to ritual mutilation elevates the victim to a higher consciousness. Through either the intense pain of the mutilation or the effects of drugs—or both—the victim hallucinates communion with the deities. Sometimes this "privilege" is reserved for the priesthood or for certain communicants of special status. In Christianity, only Jesus and the martyrs were graced with mutilation—except for a dubious mystic every now and then who miraculously bears the "stigmata," or the wounds of Christ.
In the Church of Modern Medicine, no one is excluded from the sacrifice. Until the invention of anesthesia, victims gritted their teeth and saw their gods with the clarity agony brings—until they passed out. Now the victim is "put under" in a form of mock death, so the surgeon not only has the opportunity to heal him, but bring him back from the dead as well. Of course, even that opportunity has been superceded by the refinement of local anesthesia. Now the victim can stay awake and observe the surgeon fiddling with his mortality. After the operation, of course, even children enjoy showing off their scars. If they're the children of doctors, chances are better that they'll have scars to show off, because doctors' families tend to have more surgery than anybody else. Which demonstrates that doctors believe in the sacrament's power at least as faithfully as they expect everybody else to.
One of the true tests of a fanatic is whether or not he takes his own medicine—or believes his own press releases. The fact that doctors do get in line for the sacrifice only strengthens its grounding in ceremony.
The most sinister aspect of Modern Medicine's belief in surgery is the presumption that lies behind that belief, that the priest can overcome anything because he can operate on you. You don't have to take care of yourself, we can fix you if you go wrong. All you have to do is believe enough to show up for the sacrament, which in this case is a ritual mutilation. Modern Medicine has succeeded in usurping the power of traditional religions so all of us, including the priests, rabbis, ministers, and monks, see ourselves as ultimately repairable to and by the power that resides in the tabernacle of the operating room.
To protect yourself from your doctor's belief in surgery and avoid the knife's sacramental use on your own flesh, your first step is to educate yourself. Once again, make it your business to learn more about your case than your doctor does. Books, journals, and magazines available at the public library should provide you with enough information.
You should be especially wary if your doctor recommends one of the common operations, such as tonsillectomy, hysterectomy, umbilical hernia repair, etc. Remember that the doctor doesn't view surgery as a potentially harmful invasion of your body, but as a beneficent ceremony that can't help but bestow some good. Even a trusted family doctor cannot be trusted to prescribe surgery only when it's really necessary.
You should start asking questions the moment the doctor mentions surgery. What is this operation supposed to accomplish? How does it do it? What will happen if I don't have surgery? Are there any alternatives to surgery? What are the chances the operation will not succeed in what it's supposed to do? After you've obtained your doctor's answers, you should check out everything he says on your own. Chances are good that you will find conflicting information if you dig deep enough. That's the idea.
Get a second opinion. Don't go to a doctor in the same group practice, or even to one on the same hospital staff. You may have to go out of town to reach a really independent doctor. You should ask the second doctor the very same questions that you asked the first. If you get two widely different opinions, you should first go back to the original doctor and confront him with the information. That still may not resolve the differences to your satisfaction. In that case, ask your general practitioner to hold an old fashioned consultation at which all the doctors are present with you.
This may sound like a lot of trouble to go to. But you should keep in mind that the ultimate goal is to keep you in one piece unless absolutely necessary. Don't be afraid to get a third or even a fourth opinion. Considering the enormous quantity of unnecessary surgery, the chances are quite good that what your doctor's recommending is also unnecessary. You should always keep this in mind, especially when the doctor tries to make you feel like surgery is the only answer to your problem. Not only might it not be the only answer, but it might be no answer at all. You might not even have a problem!
Don't hesitate to confront your doctor with whatever information, opinions, and feelings you gather from your "homework." You're bound to learn something from his reaction. Don't be afraid to rely on the opinions of friends, neighbors, family members, and people whom you believe have wisdom.
If you decide that surgery isn't the answer, do whatever you have to do to detach yourself from the situation. Don't be afraid of offending the doctor. Although it's best to simply declare the fact that you don't want the operation and you're not going to have it, you may feel better playing the "I'll think about it" game. Once your doctor has tried to persuade you to have surgery, he may not be able to retreat from that position and continue as your doctor. After all, if he has told you that surgery is the only avenue, he can't very well treat you some other way can he? One way or the other, if your decision to stay in one piece means you lose a doctor, you're better off.
If, on the other hand, you decide to have the operation, you still shouldn't lie back and let the ceremony proceed quite yet. Contrary to what most doctors would have you believe, it does make a lot of difference who performs the surgery. Why shouldn't it? It makes a difference who paints your house or fixes your car doesn't it? Isn't it reasonable that talent should also make a difference in who removes your gall bladder?
People often ask me how to go about picking a surgeon if they "must" have surgery. I always say that if you really "must" have surgery, you're most likely in no position to make a choice because the only "must have" situation I recognize is the emergency. And in an emergency you don't have a choice. If you're in an accident and you need surgery, you take any surgeon you can get. In any situation short of an emergency, you've got plenty of time not only to decide whether or not you need the surgery but also who should perform the operation.
Again, you start to pick a surgeon by asking questions. You should talk to several surgeons and ask each and every one: How many times have you done this operation? What's your batting average? How many of the operations have been successful? How many haven't? What's your rate of complications? What is the death rate from this operation? How many of your patients have died during or shortly after this operation? Can you refer me to some of your patients who've had this operation? Would they be willing to talk to me?
My favorite question to ask a surgeon is, "If you were out of town when the operation was performed, who would you recommend for the operation?" A variation of that is, "If you needed the operation, doctor, who would you go to?"
You should also be asking the surgeons what kind of surgery is necessary. You might be able to get away with less radical surgery than originally recommended. And don't neglect to ask each surgeon, once again, if the operation is necessary. This may sound like a waste of time once you've already decided to have the operation. But you may come across new information, or a doctor who does have an alternative treatment. In any case, if you are exposed to new information, hit the books again and check it out.
If the surgical procedure is extremely complex, it might be a good idea to call whatever surgeon has a reputation for the operation. If he is in another city and you don't want to travel—or he doesn't want to take on another case—ask him to refer you to someone closer or someone who will take you on. You should also ask friends and family members to help out in finding the right surgeon. I also have a healthy respect for the ability of the average clergyman to pick out a good doctor. No matter who refers you, or what the reputation of the surgeon, you should never let down your guard and let things go by that you don't understand to your satisfaction.
And that goes double after the operation. If the operation doesn't work out as planned, or if you suffer side effects that don't seem called for, waste no time in having them checked out. As with the side effects of a drug, the discomfort may be temporary and harmless. Or it may be deadly. When you approach a different doctor with post-operative problems, you should challenge him with the following questions: Can you give me an honest opinion with regard to the other doctor's performance on this operation? Would you give me an honest opinion even though it were to result in a malpractice suit against the other doctor? Or against your hospital?
Depending on how he answers these questions, you can decide whether or not to trust him. In this and any other medical situation, your reluctance to giye away your trust is your first defense. Make every doctor earn it, especially if he wants to mutilate you.